Provider Demographics
NPI:1356500425
Name:JRA DRUG CORP
Entity Type:Organization
Organization Name:JRA DRUG CORP
Other - Org Name:JOSE PHARMACY AND SURIGAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:SUSANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-304-0101
Mailing Address - Street 1:506 W 207TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-2609
Mailing Address - Country:US
Mailing Address - Phone:212-304-0101
Mailing Address - Fax:212-304-0788
Practice Address - Street 1:506 W 207TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-2609
Practice Address - Country:US
Practice Address - Phone:212-304-0101
Practice Address - Fax:212-304-0788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042575333600000X
NY0289653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3358113OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY2978976Medicaid